Provider Demographics
NPI:1417247834
Name:SCHOLNICK, KYLE SAMUEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:SAMUEL
Last Name:SCHOLNICK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10875 MAIN ST STE 212
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4732
Mailing Address - Country:US
Mailing Address - Phone:203-494-6958
Mailing Address - Fax:
Practice Address - Street 1:10875 MAIN ST STE 212
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030
Practice Address - Country:US
Practice Address - Phone:203-494-6958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01545213E00000X
VA0103301195213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD078772800Medicaid
DC361821YFCTMedicare PIN
MD078772800Medicaid